lesson 4 obesity

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Published on January 14, 2009

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Lesson 4 : Nutrition Disorders : Lesson 4 : Nutrition Disorders Obesity and health consequences Slide 2:  Physical Activity, Calories and Obesity: The Challenge of Advances in Technology The epidemic of obesity, diabetes and the metabolic syndrome Technology and reduced physical activity Technology and the availability of calories The need for integrated solutions Obesity: definition : Obesity: definition Chronic disease characterized by accumulation of fat. Obesity is defined as a condition when ideal body weight is exceeded by 20% Medical condition responsible for serious co-morbidity and mortality. Psychosocial consequence : Psychosocial consequence Economical impact of obesity Prejudice and Discrimination Considered lazy, incompetent and more often absent due to illness Confronted with more problems at job application : Very few executive managers with overweight in the US Epidemiology : Epidemiology 0 10 20 30 40 50 1960 1970 1980 1990 2000 2010 2020 2030 USA England Mauritius Australia Brazil Population percentage with BMI > 30kg/m2 Obesity rates: current and projected Male and Female Obesity Levels in Selected European Countries : Collated by the IOTF from recent surveys Yugoslavia Greece Romania Czech Rep. England Finland Germany Scotland Slovakia Portugal Spain Denmark Belgium Sweden France Italy Netherlands Norway Hungary Switzerland % BMI >30 30 40 30 0 40 20 10 10 20 Male and Female Obesity Levels in Selected European Countries Women Men Prevalence of Obesity among U.S. Adults, BRFSS, 1990 : Prevalence of Obesity among U.S. Adults, BRFSS, 1990 (BMI > 30) Height Weight 152 (60) 69 (153) 167 (66) 84 (186) 178 (70) 94 (207) BMI = 30 Prevalence of Obesity among U.S. Adults, BRFSS, 1991 : Prevalence of Obesity among U.S. Adults, BRFSS, 1991 Prevalence of Obesity among U.S. Adults, BRFSS, 1996 : Prevalence of Obesity among U.S. Adults, BRFSS, 1996 Slide 10: Prevalence of Obesity among U.S. Adults, BRFSS, 1999 Prevalence in 2000 = 30.5% Slide 11: 1980s = X generation 1990s = Y generation 2000s = XXL generation The Developing Generations Slide 12: Source: Mokdad et al., Diabetes Care 2000;23:1278-83. Diabetes Trends Among Adults in the U.S., BRFSS 1990 <4% 4% -6% >6% Source: Mokdad et al., Diabetes Care 2000;23:1278-83. Slide 13: Diabetes Trends Among Adults in the U.S., BRFSS 1991-92 Source: Mokdad et al., Diabetes Care 2000;23:1278-83. Slide 14: Diabetes Trends Among Adults in the U.S., BRFSS 1995 Source: Mokdad et al., Diabetes Care 2000;23:1278-83. Slide 15: Source: Mokdad et al., J Am Med Assoc 2001;286(10). Diabetes Trends Among Adults in the U.S., BRFSS 2000 What causes Obesity? : What causes Obesity? Genetic predisposition Disruption in energy balance Environmental and social factors The physiology of weight gain : The physiology of weight gain Aetiology of obesity : Aetiology of obesity IA6 Thrifty genotype - feast and famine theoryThose who are most efficient in storing energy as fat during time of famine are the survivors. Therefore that genetic predisposition is favoured in a population. When that population experiences times of constant ‘feast’ i.e. a western diet, they become obese and develop diabetes. : Thrifty genotype - feast and famine theoryThose who are most efficient in storing energy as fat during time of famine are the survivors. Therefore that genetic predisposition is favoured in a population. When that population experiences times of constant ‘feast’ i.e. a western diet, they become obese and develop diabetes. GLUCOSE SENSING IN MATURITY ONSET DIABETES OF THE YOUNG : GLUCOSE SENSING IN MATURITY ONSET DIABETES OF THE YOUNG NORMAL BASAL STATE HYPERGLYCEMIA SENSED AS EUGLYCEMIA IN MODY NORMAL STIMULATION OF INSULIN SECRETION BY HYPERGLYCEMIA GLUCOSE GLUCOSE HK G6P METABOLITES hk G6P METABOLITES HK G6P METABOLITES GLUCOSE Environmental effects on the risk for type 2 diabetes mellitus : Environmental effects on the risk for type 2 diabetes mellitus Pima Indians living “on the rez” in Arizona have among the highest prevalences of diabetes and obesity of any group in the country. However, most of the Pima in Mexico are lean and nondiabetic. The difference? The Mexican Pima still live a subsistence lifestyle, farming beans and corn in the arid mountains. Prevalence of Type 2 Diabetes by Weight : Prevalence of Type 2 Diabetes by Weight Slide 24: The “Thrifty” Hypothesis FAVORING ENERGY UTILIZATION The Grasshopper FAVORING ENERGY STORAGE The Ant FEAST FAMINE FEAST FAMINE REPRO- DUCTIVE ADVANTAGE Normal glucose tolerance : Normal glucose tolerance 80 120 160 200 240 280 320 360 400 Plasma glucose (mg/dl) 0 60 120 180 Time (min) Normal 0 50 100 150 Plasma insulin (uU/ml) 0 60 120 180 Time (min) Impaired glucose tolerance:Hyperinsulinemia and insulin resistance : Impaired glucose tolerance:Hyperinsulinemia and insulin resistance 80 120 160 200 240 280 320 360 400 Plasma glucose (mg/dl) 0 60 120 180 Time (min) Impaired glucose tolerance Normal 0 50 100 150 Plasma insulin (uU/ml) 0 60 120 180 Time (min) Insulin Resistance in Type 2 DM : Insulin Resistance in Type 2 DM 0 100 200 300 400 Glucose Disposal Rate (mg/M2/min) 10 100 1000 10000 Insulin Concentration (uU/ml) Diabetes Control INSULIN-STIMULATED GLUCOSE UPTAKE IN MUSCLE AND FAT : INSULIN-STIMULATED GLUCOSE UPTAKE IN MUSCLE AND FAT Slide 29: UNDERSTANDING TYPE 2 DIABETES LIPIDS CARBOHYDRATE WHICH IS THE CART AND WHICH IS THE HORSE? : WHICH IS THE CART AND WHICH IS THE HORSE? Is Insulin Resistance a Cause or Effect of Diabetes? : Is Insulin Resistance a Cause or Effect of Diabetes? “Beta cell hyperresponsiveness is the earliest event in the development of type 2 diabetes” in rhesus monkeys, preceding the onset of insulin resistance. Hansen and Bodkin, Am J Physiol 259:R612 (1990) What does the “thrifty phenotype” look like in a calorie restricted, natural setting? : What does the “thrifty phenotype” look like in a calorie restricted, natural setting? Aboriginal Australians exposed to Western diet/lifestyle develop type 2 diabetes and obesity in alarming proportions, similar to native Americans. O’Dea has studied aboriginal Australians living in the bush and has found: Lean individuals: average BMI 16 kg/m2 They are relatively hypoglycemic (68 mg/dl) while having relative hyperinsulinemia (13 uU/ml) Fasting hyperinsulinemia predictstype 2 diabetes independent of insulin resistance : Fasting hyperinsulinemia predictstype 2 diabetes independent of insulin resistance Among 262 healthy Pima Indians, 48 (18%) developed diabetes during a 4-6 year follow-up period. Fasting insulin and insulin responsiveness predicted the development of diabetes and the concomitant decline in insulin secretion. Pratley, Weyer, Hanson, Tataranni, Shuldiner, and Bogardus (2000) Is Insulin Resistance a Cause or Effect of Diabetes? : Is Insulin Resistance a Cause or Effect of Diabetes? Isolated insulin resistance is well tolerated in transgenic animals and does not, by itself, lead to diabetes. Beta cell abnormalities, on the other hand, do predispose to overt diabetes in animal models. Isolated hyperinsulinemia can cause insulin resistance just as well as insulin resistance can cause hyperinsulinemia. Caloric Excess : Caloric Excess Technological advances have taken away much of the activity in our lives : Technological advances have taken away much of the activity in our lives Fewer active jobs Greater reliance on motorised transport Energy-saving devices in the home, at work and shopping environment Attractive and cheap home screen entertainment CHALLENGE IS TO COUNTERACT THESE EFFECTS High-Tech increases Body Weight : Cellular phones and remote controls deprive us from walking! 20 times daily x 20 m = 400 m Walking distance lost/year400x365 = 146,000 m 146 km = 25 h of walking 1 h of walking = 113-226 kcal Energy saved =2800-6000 kcal Rössner, 2002 High-Tech increases Body Weight ? 0.4-0.8 kg adipose tissue Biological and cultural mismatches to the modern environment : Biological and cultural mismatches to the modern environment FOOD Strong signals to eat Weak signals to stop Increased availability Eating is rewarding No viable alternatives Eating well is high status ACTIVITY Weak activity signal Strong signals to stop Reduced availability Inactivity is rewarding Inactivity is a viable alternative Inactivity is high status Slide 39: The Evolution of Man Since 1850 Slide 40:  Daily Energy Expenditure in Primitive Hunter - Gatherer -Farmers versus Sedentary Adults in USA Machiguenga Indians in Peru Kilocalories per Kilogram per Day ? = 42% ? = 27% Montgomery E., Fed Proceed 37:61-64, 1978 Slide 41: Denis Diderot - Pictorial Encyclopedia of Trades and Industry ( France 1740-1780) Slide 44: “From the time of the Roman Conquest to the time of the Civil War in the United States (1860s), there was no improvement in the efficiency in the movement of military troops or supplies. This was changed by the use of the steam engine to power ships and the locomotive.” The Men Who Dared:Building the Transcontinental Railroad Stephen Ambrose 2000 Slide 45: “Required daily activity” between 1850 and 1950 for many people in technologically advancing societies decreased substantially and this decrease was easily observable. Since the 1950s there has continued to be a decline in “required daily activity” in many societies, but this decrease in more subtle and less well documented. Decline in Daily Required Activity Resulting from the Industrial Revolution Slide 46: “ These lumberjacks worked 10-12 hours , six days per week from April through November logging the giant redwood trees. Their primary equipment included 9-pound axes, two-man saws, buck saws, hand winches and wedges.” History of the Sierra Nevada C. Taylor, 1996 Required Daily Activity High for Many Workers 1n 1900 Slide 47: RMR = 1Kcal/Kg/Hr (VO2 = 3.5 ml/kg/min) 50 kg body weight = 50 x 24 = 1200 Kcal/day 70 kg body weight = 70 x 24 = 1680 Kcal/day 100 kg body weight = 100 x 24 = 2400 Kcal/day PAL = 1.0 WHO Obesity Guidelines, 2000 Technical Report Series 894 Slide 48: Physical Activity Level - PAL Multiple of Resting Metabolic Rate MEN WOMEN RMR 1.00 1.00 Very Light <1.46 <1.41 Light 1.46 - 1.65 1.41 - 1.55 Moderate 1.66 - 1.90 1.56 - 1.75 Heavy 1.91 - 2.25 1.76 - 2.05 Exceptional >2.25 >2.05 WHO Obesity Guidelines, 2000 - Technical Report Series 894 Slide 49: Variations in Energy Expenditure Due to Daily Physical Activity PAL 1.0 1.30 1.58 1.75 2.00 2.65 2.80 Kcal/day* 1680 2184 2644 2940 3360 4550 4800 RMR Sedentary Moderately Active Very Active Primitive Man Finnish Lumberjacks Light Activity * Kcal/day for 70 kg person WHO GOAL Slide 50: Declines in on-the-job energy expenditure during the past 50 years Labor savings devices that decrease required energy expenditure • Computers • Satellites • Electric typewriters • Television • Electric calculators • Video cameras and recorders • Photocopy machines • Robotics • Telefax machines • Automated on-job equipment • Telephones • Gas/electric home equipment • digital • Microwave ovens • portable • • answering machines • • voice-mail People movers - escalators Wireless technology Slide 51:  Frequent Decreases in Short Bouts of Low Intensity Activity Can Significantly Alter Energy Balance Over 5 years Only 165 Kcal/week equal in energy to 10.1 pounds or 4.6 kilograms of body fat in 5 years If 50 kilogram person exchanged walking around office for sitting at computer for 5 minutes per hour, 8 hours per day, 5 days per week, 50 weeks per year for 5 years = amount of energy in 10.1 pounds or 4.6 kilogram body fat. Slide 52: Wireless Technology Likely to Decrease Required Daily Activity Technology and Inactivity - Future Projections for further decline in energy expenditure in the population due to continued decrease in daily required physical activity over next two decades Reduce commuting to work Computer to bank, shop, etc. More job tasks automated New technologies Slide 53: Alan Greenspan - Chairman, Board of Governors of the Federal Reserve System The major cause for the continued increase in the US economy without an increase in inflation throughout the 1990s was an increase in individual worker productivity. Slide 54: It’ll cut down on the work breaks! Slide 55: Individual worker productivity increased by: • Working more hours - in 1998 US worker averaged 1950 hours/year while European workers average 1558 hours/year on-the-job: 25% more hours per year. • Increase in worker efficiency by reducing amount of physical movement time. Moving around is a major cause of inefficiency for computer & communications-based industry. Slide 56: A Problem and challenge! The US model used to increase economic productivity is considered an approach to be emulated by leaders in many developing countries Slide 57:  MOSPA Study Population Adults 25 - 65 Years • Beijing China (627 men, 575 women) • Friuli Italy (700 men, 391 women) • Warsaw Poland (535 men, 469 women) • WHO-MONICA project monitors global trends and determinants of CVD • MOSPA (MONICA Optional Study of Physical Activity) questionnaire was developed to assess physical activity behaviors of participating MONICA sites • MOSPA data collected 1987-1994 Slide 58: Percent Time Spent by Adults in Different Categories of Physical Activity in China, Italy, and Poland Percent Time Spent by Adults in Different Categories of Physical Activity in China, Italy, and Poland % time Data from WHO MONICA report, 2000 MEN WOMEN Slide 59: Increased Time at Computer/TV/Video Decreases Time for Leisure-Time Physical Activity > Slide 60: Time Spent by USA Children Viewing Electronic Media Hours/day Kids and Media. A Kaiser Family Foundation Report, November 1999, Menlo Park, CA National sample of 3,158 children in the USA "The Media Generation" 2.8 5.2 Slide 61: Why don’t you get off the computer and watch TV? Slide 62: New Remote Control Can Be Operated by Remote No more leaning forward to get remote from coffee table means greater convenience for TV viewers. Television watching became even more convenient with Sony’s introduction of a new remote-controlled remote control. Slide 64: Potential reduction of leisure-time physical activity as computer/communication technology advances penetrate the masses Technology and Leisure Activity • Increased participation in computer games • Increased use of computer as a communication device for recreational purposes (chat rooms, etc.) • Increased use of home-based video - including video access on the internet • Continued watching of television - cable, satellite Slide 65: Physical Activity and Obesity • Risk of overweight low if PAL is = 1.75 A PAL of >1.75 is needed to prevent “unhealthy weight gain” [based on results of 40 international studies] • Prevalence of PAL =1.75 rapidly increasing in developed and developing countries - especially as they adopt computer and communication technology. WHO Obesity Guidelines, 2000 - Technical Report Series 894 Slide 66: Variations in Energy Expenditure Due to Daily Physical Activity PAL 1.0 1.30 1.58 1.75 2.00 2.65 2.80 Kcal/day* 1680 2184 2644 2940 3360 4550 4800 BMR Sedentary Moderately Active Very Active Primitive Man Finnish Lumberjacks Light Activity * Kcal/day for 70 kg person WHO GOAL Slide 67: Variations in Energy Expenditure Due to Daily Physical Activity PAL 1.0 1.30 1.52 1.75 2.00 2.65 2.80 Kcal/day* 1680 2184 2553 2940 3360 4550 4800 BMR Sedentary Moderately Active Very Active Primitive Man Finnish Lumberjacks Light Activity * Kcal/day for 70 kg person GOAL 30 Min. Mod Intensity - USA (1995) 60 Min. Mod Intensity - Canada (2000) & IOM (2002) Slide 68: Variations in Energy Expenditure Due to Daily Physical Activity PAL 1.0 1.30 1.52 1.75 2.00 2.65 2.80 Kcal/day* 1680 2184 2553 2940 3360 4550 4800 BMR Sedentary Moderately Active Very Active Primitive Man Finnish Lumberjacks Light Activity * Kcal/day for 70 kg person GOAL 30 Min. Mod Intensity - USA (1995) +756 Kcal /day (WHO 2000) 60 Min. Mod Intensity - Canada (2000) ACTIVITY INTERVAL!! : ACTIVITY INTERVAL!! Slide 71: Body Mass Energy Intake Energy Expenditure Large portion size High calorie density Low cost Occupational Transportation Household Sedentary Recreational ? Factors Contributing to Recent Increases in Body Mass in the USA & Other Developed Countries Slide 72: Low cost of increasing portion size (supersizing or value marketing) is a major profit item for restaurants & fast food markets 7-Eleven Gulp to Double Gulp Coke Classis 37 cents buys 450 more calories (150 to 600 calories) Movie popcorn (unbuttered) - from small to large increases cost by $1.31 but increases calories from 400 to 1160 Cinnabon - Ordering a Cinnabon costs 48 cents more than a Minibon but increases calories from 300 to 670 Advances in Technology Throughout the Food Supply Chain Has Reduced the Cost of High Calorie Low Nutrient Food Slide 73: High calorie foods and drinks replacing low calorie items Starbucks Venti Coconut Crème Frappuccino “coffee” = 870 calories Adding “Value Meals” for single item orders Burger King Whopper ($2.24 & 680 calories) to Whopper Values Meal - King ($4.80 & 1,710 calories Advances in Technology Throughout the Food Supply Chain Has Reduced the Cost of High Calorie Low Nutrient Food Slide 74: Double Cheese Burger = 690 Super Size Coke = 280 Biggie Fries = 570 TOTAL = 1,540 CALORIES 62 grams of fat High Caloric Density Food Always Available at Low Cost Ad in Sports Illustrated 15/06/02 Slide 75: Introduction of New Larger Portions in the USA Young & Nestle. AJPH,92:246, 2002 Dinner plate diameter 25% larger in 2000 vs. 1990 Slide 76: McDonalds’ Worldwide Influence 28,000 restaurants worldwide - 2,000 new/year Hire more than one million people per year Largest private owner of real estate property in world More $$ spent on advertising than any other US corp. 90% of children can identify Ronald McDonald - only Santa Claus has higher recognition factor The McDonald’s arches more widely recognized than the Christian cross FAST FOOD NATION - Eric Schlosser 2001 Obesity and sedentary living in European adultsMartinez-Gonzalez et al. 1999, IJO, 23, 1192-1201 : Obesity and sedentary living in European adultsMartinez-Gonzalez et al. 1999, IJO, 23, 1192-1201 % Obese Hrs sat/wk Hourly movement counts of obese and non-obese adults: Weekdays : Hourly movement counts of obese and non-obese adults: Weekdays Cooper et al., EJCN, 2000 Hourly movement counts of obese and non-obese subjects: Weekends : Hourly movement counts of obese and non-obese subjects: Weekends Slide 81: Eat to Live! Slide 82: “EAT TO LIVE” Intake = Expenditure Weight Stable “LIVE TO EAT” Intake > Expenditure Obese Ageing and Energy Expenditure : Ageing and Energy Expenditure James, Ralph and Ferro-Luzzi, 1989 Kcals/d Intenseexercise Occupational Sitting, coffee, smoking Basal metabolicrate 70 kg, Aged 25 years 70 kg, Aged 70 years 4000 2000 0 3000 1000 Fat as the Macronutrient Culprit : Fat as the Macronutrient Culprit Adapted from WHO Consultation 1998 Protein Carbohydrate Fat Energy content per g Ability to end eating Ability to suppress hunger Storage capacity Pathway to transfer excess to alternative compartment Ability to stimulate own oxidation 4 High High Low Yes Excellent 4 Moderate High Low Yes Excellent 9 Low Low High No Poor Dietary fat : Dietary fat Typical Belgian diet Carbohydrate 40–50% Protein 15–20 % Fat 40% Desired Belgian diet Carbohydrate 45–55% Protein 15–20 % Fat 30% Staessen L. et al. : Ann. Nutr. Metab. 1998; 42; 151-159 Energy needs : Contribution of fat, protein, carbohydrate and alcohol to the energy intake in the average British diet Energy needs Measurement of Energy Intake Consequences of obesity : Consequences of obesity Blindness in a child... : …because of fat infiltrationin eyelids... Blindness in a child... Obesity : Definition : Obesity : Definition APPLE TYPE :Central or abdominal adiposity (ANDROID) ? increased WHR & associated with higher morbidity risk. ? > ? Slide 90: Android obesity or Obesity : Definition : Obesity : Definition PEAR TYPE : GYNOID or typical female distribution of fat : less health risks Slide 92: Gynoid obesity or Slide 93: visceral fat measurement using standard procedure at L5 Waist to hip circumferences : Waist to hip circumferences Correlates with visceral fat (Ashwell et al, 1985 Coefficient of Variation in measurement about 2% WHO recommendations on methdology Epidemiological correlates with obesity morbidity Obesity : Definition : Obesity : Definition WHR > 0.95 (?) & > 0.80 (?) : increased health risk Visceral Obesity and the Insulin Resistance Syndrome : Visceral Obesity and the Insulin Resistance Syndrome Excess visceral abdominal adipose tissue Insulin resistance andhyperinsulinaemia Atherogenic dyslipidaemia Total-C ? LDL-C ? HDL-C ? Triglycerides ?Small, dense LDL ? Apolipoprotein-B ? Hypertension LVH Congestive heart failure Prothrombotic state PAI-1 ? Factor VII ? Fibrinogen ? Glucose intolerance Slide 97: Metabolic Syndrome Defined by ATP III (2001) as = 3 of any of the following Waist circumference = 102 cm in men and 88 cm in women Triglyceride concentration = 150 mg/dL (1.69 mmol/L HDL-C = 40 mg/dL (1.04 mmol/L) in men and = 50 mg/dL (1.29 mmol/L) in women Blood pressure = 130/85 mm Hg Blood glucose = 110 mg/dL (6.1 mmol/L) Slide 98: Prevalence of Metabolic Syndrome in Men and WOMEN - USA MEN (24.0%) WOMEN (23.4%) Total = 47 million people NHANES - 1994 AGE -YEARS Mexican American = 31.9% Obesity treatmentWhy? :  Obesity treatmentWhy? Obesity is a chronic condition Associated with co-morbidities Type 2 diabetes Arthritis Associated with risk factors Hypertension Dislipidaemia Coronary heart disease Imposes a substantial economic burden Abdominal Adiposity Increases CHD Risk Independently of BMI : Abdominal Adiposity Increases CHD Risk Independently of BMI Low (?73.6) Medium (73.7-81.7) High (?81.8) WaistCircumference tertiles (cm) High(?25.2) Medium(22.2-25.1) Low(?22.1) BMI tertiles (kg/m2) Age-adjusted CHD incidence/100 000 person-years Rexrode KM et al. JAMA, 1998; 280: 1843-8 77 46 55 106 89 97 128 110 83 Health consequences of obesity : Health consequences of obesity Cardiovascular disease Type 2 diabetes Hypertension Dyslipidaemia Ischaemic stroke Sleep apnoea Degenerative joint disease Some types of cancer Gallstones Gynaecologic irregularities Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm. Accessed July 31, 1998. Relative risk of health problems associated with obesity : Greatly Increased Moderately increased Slightly increased (relative risk >>3) (relative risk c. 2-3) (relative risk c. 1-2) Diabetes Coronary heart disease Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer) Gall bladder disease Hypertension Reproductive hormone abnormalities Dyslipidaemia Osteoarthritis (knees) Polycystic ovary syndrome Insulin resistance Hyperuricaemia and gout Impaired fertility Breathlessness Fetal defects arising from maternal obesity Sleep apnoea Low back pain Increased anaesthetic risk IOTF Report Relative risk of health problems associated with obesity Proportion of disease prevalence attributable to obesity : Proportion of disease prevalence attributable to obesity Type 2 diabetes Hypertension Coronary heart disease Gallbladder disease Osteoarthritis Breast cancer Uterine cancer Colon cancer Wolf et al. Obes Res. 1998;6:97-106. 57% 17% 17% 30% 14% 11% 11% 11% Obesity related cardiovascular and renal risk : Obesity related cardiovascular and renal risk Obesity is a independent risk factor for the development of CV and Renal disease, even in the absence of other pathologies Burden of Disease : Burden of Disease Burden of disease analysis gives a unique perspective on health. Fatal and non-fatal outcomes are integrated, but can be examined separately as well. YLL - Years of Life Lost due to premature mortality +YDL - Years of Life Lost due to Disability DALY Disability Adjusted Life Years one DALY is one lost year of ‘healthy’ life Risk Factor : Risk Factor A condition, physical characteristic, or behavior that increases the probability (the risk) that a currently healthy individual will develop a particular disease. Types of risks factors: Environmental Behavioral Social Genetic Lifestyle Diseases and Risk Factors : Lifestyle Diseases and Risk Factors Diabetes Hypertension Heart Disease Cancer Genetic Obesity Eating Patterns Physical Activity Smoking Urbanisation Coronary Heart Disease : Coronary Heart Disease Major risk factors High Total Cholesterol or LDL, Low HDL Elevated Homocysteine (low folate intake) Hypertension Cigarette Smoking Obesity Diabetes Mellitus Sedentary Lifestyle Excessive Alcohol Factors which Influence Blood Lipid Levels : Factors which Influence Blood Lipid Levels Detrimental effect Saturated fat Trans fatty acids Dietary cholesterol Diabetes Obesity central abdominal Obesity Sedentary Lifestyle Beneficial effect Vegetables and fruits Polyunsaturated fatty acids Monounsaturated fatty acids Omega 3 fatty acids Dietary fibre Moderate alcohol Physical activity Risk Factors for Hypertension : Risk Factors for Hypertension Detrimental effect Age Gender Smoking Obesity Sodium Alcohol Stress Beneficial effect Potassium Omega -3 fatty acids Physical activity Health Agencies’ Recommendations for Prevention of Hypertension : Health Agencies’ Recommendations for Prevention of Hypertension Smoking cessation Reduce weight Reduce salt Moderate alcohol Reduce fat Increase fruit and vegetables Regular fish consumption Increase physical activity Risk Factors for Diabetes : Risk Factors for Diabetes Genetic Age Gender Obesity Eating pattern Physical Activity Hypertension Gestational Diabetes Urbanisation Trend in Prevalence of Obesity*:NHANES Data : Trend in Prevalence of Obesity*:NHANES Data Kuczmarski RJ, et al. JAMA. 1994;272:205-211. *BMI ? 27.3 mg/m2 for women; ? 27.8 kg/m2 for men Type 2 Diabetes in the Pediatric Population: First Nation Data : Type 2 Diabetes in the Pediatric Population: First Nation Data Prevalence of impaired glucose tolerance among children and adolescents with marked obesity : Prevalence of impaired glucose tolerance among children and adolescents with marked obesity Aim Determine the prevalence of IGT in a multiethnical cohort of 167 children and adolescents OGTT with glucose, insulin, C-peptide Sinha R, Fish G et al. NEJM 2002; 346: 802-10 Prevalence of impaired glucose tolerance among children and adolescents with marked obesity : Prevalence of impaired glucose tolerance among children and adolescents with marked obesity Results 25 % IGT in children (4-10y) 21 % IGT in adolescents (11-18y) Increased insulin values in IGT 4 % insidous DM2 in adolescents Sinha R, Fish G et al. NEJM 2002; 346: 802-10 Prevalence of impaired glucose tolerance among children and adolescents with marked obesity : Prevalence of impaired glucose tolerance among children and adolescents with marked obesity Conclusion High prevalence of IGT in children and adolescents with obesity > 95 percentile age and sex. Ethnicity not important IGT accompanied by insulin resistance with adequate ?-cell function DM2 accompanied by insulin deficiency indicative of ?-cell failure Sinha R, Fish G et al. NEJM 2002; 346: 802-10 Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study : Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study Colditz GA, et al. Ann Intern Med. 1995;122:481-486. Slide 119: Adapted from Chan JM et al. Diabetes Care 1994; 17: 961-9 Adapted from Chan JM et al. Diabetes Care 1994; 17: 961-9 Colditz et al. Ann Intern Med 1995; 122: 481-6 a Age-adjustedrelative risk of type 2 diabetes Obesity is a risik factor for type 2 diabetes Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study : Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study Colditz GA, et al. Ann Intern Med. 1995;122:481-486. Diet, lifestyle and the risk of type 2 diabetes mellitus in women : Diet, lifestyle and the risk of type 2 diabetes mellitus in women Risk factors for type 2 diabetes obesity en weight gain Physical inactivity, independent of obesity Low fibre and high GI diet Specific FA Aim Study the combined effect of these factors Hu FB, Manson JE et al. NEJM, 2001; 345:790-7 Diet, lifestyle and the risk of type 2 diabetes mellitus in women : Diet, lifestyle and the risk of type 2 diabetes mellitus in women Study population Nurses’ Health Study from 1980-1996 89 941 patients of total 121 700 Exclusion diabetes, cancer and CV disease Dietary-Interview questionnaire 61 items, semi-quantitive each diet factor: score 1-5 for the 4 nutrients, dependent on quintile intake Hu FB, Manson JE et al. NEJM, 2001; 345:790-7 Diet, lifestyle and the risk of type 2 diabetes mellitus in women : Diet, lifestyle and the risk of type 2 diabetes mellitus in women Investigation of non-nutrition related factors Smoking Menopausal status/substitution Body weight Physical activity Family history of diabetes NEJM, 2001; 345:790-7 Hu FB, Manson JE et al. Diet, lifestyle and the risk of type 2 diabetes mellitus in women : Diet, lifestyle and the risk of type 2 diabetes mellitus in women Defining low-risk group (LRG): BMI<25 kg/m2 Physical activity :30 min/d moderate activity Smoker : Non-Smoker alcohol: 0.5U/d diet: Little trans fat, low glycemic index, high fibre intake, High ration PUFA NEJM, 2001; 345:790-7 Hu FB, Manson JE et al. Diet, lifestyle and the risk of type 2 diabetes mellitus in women : Diet, lifestyle and the risk of type 2 diabetes mellitus in women 16 year follow-up diagnose DM according National Diabetes Data Group Relative risks calculated : incidence of diabetes in LRG incidence diabetes amongst rest of the women ‘population attributable risk’ Estimation of the percentage of diabetes type 2 which would not occur if all women were to be placed in the LRG. Hu FB, Manson JE et al. NEJM, 2001; 345:790-7 Slide 126: Most important risk factor ! 61% of new cases DM result of overweight 87 % new cases preventable if all women placed in LRG NEJM 2001, 345:790-797 Slide 127: Conclusion combination of different factors can prevent Diabetes BMI ? 25 Diet : high fibre intake; PUFA, Low SFA; trans fats and GI Regular physiacl activity Non Smoker Moderate alcohol use incidence of diabetes approx. 90 % lower in this group Slide 128: Behavior changes can prevent diabetes Most important determinant for DM 2 OVERWEIGHT BUT Present prevalence still increasing Current therapy strategies not sufficient Education Necessary Risk Factors for Cancers : Risk Factors for Cancers Cigarettes/Tobacco Betel Nut (lime?) Hepatitis B Obesity Hyperglycaemia Physical Activity Dietary Factors Fat Fibre Meat (cooking methods) Alcohol Vegetables and Fruits Omega 3 fatty acids Slide 130: Can Johnny come out and eat? Can physical activity prevent weight gain? : Can physical activity prevent weight gain? Attenuated weight gain with recreational physical activity: MEN : Attenuated weight gain with recreational physical activity: MEN 0 26-39 40-54 55+ -26 Baseline weight gain of inactive Walking Running Cycling Golf NHANES Study, USA Age group Prospective studies on the effect of physical activity/fitness on long term weight gain. : Prospective studies on the effect of physical activity/fitness on long term weight gain. DiPietro et al. 1998 7 yrs *men, *women Coakley et al. 1998 4 yrs *men Lewis et al. 1998 7 yrs *men, *women Williamson et al. 1993 10 yrs *men, *women Rissanen et al. 1991 5 yrs *men, *women Estimated relative odds of weight gain category by recreational physical activity: WOMEN : Estimated relative odds of weight gain category by recreational physical activity: WOMEN Williamson et al., (1993), IJO, 17, 279-86 Slide 135: Effects of an Obesity Prevention and Exercise Program on the Development of NIDDM in Men and Women with Impaired Glucose Tolerance Tuomilehto, et al. NEJM 344:1343-1350, 2001 Percent of Participants Free of Diabetes P <0.001 58% 80% Slide 136: Effects of Metformin or Lifestyle Interventions on the Incidence of Developing Diabetes in High Risk Men and Women Cases per 100 person-years Placebo Metformin Lifestyle Diabetes Prevention Program Research Group.NEJM,2002:346:393-403 N = 3234 Men & women • Overweight • Sedentary • High glucose PA = 150 min/w Weight - 12 lbs. Metformin = 850 mg 2 x day 2.8 yr. follow-up Slide 137: Recent natural gas and electric energy shortage may be our salvation in California. Eco House at Humbolt State University generates all its power needs via human power generation using cycle ergometers connected to generators. Reversal of Downward Trend in Daily Physical Activity Will Require Innovative and Integrated Approaches Slide 138: Integrated Programs to Reduce Obesity Public education via mass media - “set the stage” Community-based programs for physical activity and nutrition - promote individual behavior change Environmental change to promote activity - sidewalks, parks, showers @worksites, mall walking, etc. Policy change to promote activity and healthy eating - schools (PE & recess), worksites, government, etc. Incentive/penalty programs - health insurance companies: third-party payment can be a disincentive Spectrum of obesity management : Spectrum of obesity management Weight loss has beneficial health effects : Weight loss has beneficial health effects Improved glycaemic control Reduced blood pressure Improved lipid profile 20% reduction in premature mortality in overweight women with obesity-related health conditions Goldstein DJ. Int J Obesity, 1991 A weight loss of ? 5% in obese individuals with comorbid type 2 diabetes, hypertension or dyslipidaemia resulted in: Obesity management: objectives : Obesity management: objectives Promotion of weight loss Long-term weight maintenance Long-term prevention of weight gain Improvement of risk factors Encouragement of active lifestyle Improvement in quality of life Change in eating patterns THE MANAGEMENT OF OBESITY: AN INTEGRATED APPROACH : THE MANAGEMENT OF OBESITY: AN INTEGRATED APPROACH Obesity is a serious medical condition requiring long-term management Management needs to be flexible and integrate different therapeutic approaches according to individual patient needs including Dietary management Lifestyle modification Physical activity Drug therapy Surgery WEIGHT MANAGEMENT : WEIGHT MANAGEMENT Weight Keep Weight Slight Reduction Moderate Red. (medical useful) Normalising Weight (Not realistic and contraproductive) Weight Gain Obesity Overweight Normal Weight Years PATIENT EXPECTATIONS : PATIENT EXPECTATIONS Reference: Foster et al. J Consult Clin Psych 1997; 65(1): 79-81 CONTRASTING PATIENT AND PHYSICIAN EXPECTATIONS : CONTRASTING PATIENT AND PHYSICIAN EXPECTATIONS Reference: Ziegler O, Meyer L, Guerci B et al. In press. Slide 147: And finally, we need to recognize that we do not know how to successfully “treat” obesity… The question we need to address is: How do we help people maintain health in an environment conducive to people weighing more? THE NEED FOR REALISTIC GOALS IN OBESITY MANAGEMENT : THE NEED FOR REALISTIC GOALS IN OBESITY MANAGEMENT Shift focus from changing appearance to improving health Consider healthier weight over time - not ideal weight Sustained moderate weight loss of 5-10kg (5-10% of initial body weight) Elevated BP Blood sugar concentrations Serum triglycerides HDL-cholesterol levels Long-term management of obesity : Long-term management of obesity Efficacy of long-term treatment requires Patient motivation for weight loss Patient satisfaction with weight loss Patient satisfaction with treatment Best achieved by combination of Low-fat diet Increased physical activity Well-tolerated pharmacotherapy

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